Eating Disorders:
Over-exercising, Over Activity

continued from

Cognitive Distortions in Activity Disorder

DICHOTOMOUS, BLACK-AND-WHITE THINKING

• If I don't run, I can't eat.

• I either run an hour or it's not worth it to run at all.

OVERGENERALIZATION

• Like my Mom, people who don't exercise are fat.

• Not exercising means you are lazy.

MAGNIFICATION

• If I can't exercise, my life will be over.

• If I don't work out today, I'll gain weight.

SELECTIVE ABSTRACTION

• If I can go to the gym, I am happy.

• I feel great when I exercise, so if I exercise I'll never be depressed.

SUPERSTITIOUS THINKING

• I must run every morning or something bad will happen.

• I must do 205 sit-ups every night.

• I can't stop at 1 hour and 59 minutes, it has to be exactly 2 hours, so when the fire alarm went off I couldn't get off the Stairmaster, I had to keep going, even if the gym was burning down.

PERSONALIZATION

• People are looking at me because I'm out of shape.

• People admire runners.

• I am a runner, it's who I am, I could never give it up.

ARBITRARY INFERENCE

• People who exercise get better jobs, relationships, and so on.

• People who exercise don't get sick as much.

DISCOUNTING

• My doctor tells me not to run, but she is flabby so I don't listen to her.

• No pain, no gain.

• Nobody really knows the effects of not having a period anyway, so why should I worry?

Physical Symptoms of Activity Disorder

• A key in determining if a person is developing an activity disorder is if she has the symptoms of overtraining (listed below) yet persists with exercise anyway. Overtraining syndrome is a state of exhaustion in which individuals will continue to exercise while their performance and health diminish. Overtraining syndrome is caused by a prolonged period of energy output that depletes energy stores without sufficient replenishment.

Symptoms of Over-Training

• Fatigue

• Reduction in performance

• Decreased concentration

• Inhibited lactic acid response

• Loss of emotional vigor

• Increased compulsivity

• Soreness, stiffness

• Decreased maximum oxygen uptake

• Decreased blood lactate

• Adrenal exhaustion

• Decreased heart rate response to exercise

• Hypothalamic dysfunction

• Decreased anabolic (testosterone) response

• Increased catabolic (cortisol) response (muscle wasting)

The only cure for the above symptoms is complete rest, which may take a few weeks to a few months. To a person with activity disorder, resting is like giving up or giving in. This is similar to an anorexic who feels like eating is "giving in." When giving up their exercise behaviors, those with activity disorder will go through psychological and physical withdrawal, often crying, yelling, and making statements like

• I can't stand not exercising, it's driving me crazy, I'd rather die.

• I don't care about the consequences, I have to work out or I'll turn into a fat blob, hate myself, and fall apart.

• This is worse torture than any effects of the exercise, I feel like I'm dying inside.

• I can't even stand being in my own skin, I hate myself and everyone else.

It is important to note that these feelings diminish over time but need to be carefully attended to.

Approaching an Individual With an Activity Disorder

In January 1986, the Physician and Sports Medicine Journal discussed the subject of pathogenic (negative) exercise in athletes and listed recommendations for approaching athletes practicing one or more pathogenic weight control techniques. The recommendations can be reformulated and extended for use when approaching individuals with activity disorders who are not necessarily considered athletes.

Guidelines for Approaching the Activity Disordered Individual

• A person who has good rapport with the individual, such as a coach, should arrange a private meeting to discuss the problem in a supportive style.

• Without judgment, specific examples should be given regarding the behaviors that have been observed that arouse concern.

• It is important to let the individual respond but do not argue with him or her.

• Reassure the individual that the point is not to take away exercise forever but that participation in exercise will ultimately be curtailed through an injury or by necessity if evidence shows that the problem has compromised the individual's health.

• Try to determine if the person feels that he or she is beyond the point of being able to voluntarily abstain from the problem behavior.

• Do not stop at one meeting; these individuals will be resistant to admitting that they have a problem, and it may take repeated attempts to get them to admit a problem and/or seek help.

• If the individual continues to refuse to admit that a problem exists in the face of compelling evidence, consult a clinician with expertise in treating these disorders and/or find others who may be able to help. Remember that these individuals are very independent and success oriented. Admitting they have a problem they are unable to control will be very difficult for them.

• Be sensitive to the factors that may have played a part in the development of this problem. Activity disordered individuals are often unduly influenced by significant others and/or coaches who suggest that they lose weight or who unwittingly praise them for excessive activity.

Risk Factors

One outstanding difference between the eating disorders and activity disorders seems to be that there are more males who develop activity disorders and more females who develop eating disorders. Exploring the reason for this may provide a better understanding of both. What are the causes that contribute to the development of an activity disorder? Why do only some individuals with eating disorders have this syndrome and others who have this syndrome don't have eating disorders at all? What we do know is that the risk factors for developing an activity disorder are varied, including sociocultural, family, individual, and biological factors, and are not necessarily the same ones that cause the disorder to persist.

Sociocultural

In a society that places a high value on independence and achievement combined with being fit and thin, involvement in exercise provides a perfect means for fitting in or gaining approval. Exercise serves to enhance self-worth, when that self-worth is based on appearance, endurance, strength, and capability.

Family

Child-rearing practices and family values contribute to an individual choosing exercise as a means of self-development and recognition. If parents or other caregivers endorse these sociocultural values and they themselves diet or exercise obsessively, children will adopt these values and expectations at an early age. Children who learn not only from society but also from their parents that to be acceptable is to be fit and thin may be left with a narrow focus for self-development and self-esteem. A child reared with phrases such as "no pain, no gain," may endorse this attitude wholeheartedly without the proper maturity or common sense to balance this notion with proper self- nurturing and self-care.

Individual

Certain individuals seem predisposed to need a high level of activity. Individuals who are perfectionists, achievement oriented, and have the capacity for self-deprivation will be more likely to seek out exercise and become addicted to the feelings or other perceived benefits the exercise provides. Additionally, individuals who develop activity disorder seem outwardly independent, unstable in their view of themselves, and lacking in their ability to have fully satisfying relationships with others.

Biological

Just as with eating disorders, researchers are exploring what biological factors may contribute to activity disorders. We know that certain individuals have a biologically based predisposition to obsessive thoughts, compulsive behaviors, and, in women, amenorrhea. We know that in animals the combination of food restriction and stress causes an increase in activity level and, furthermore, that food restriction with increased activity can cause the activity to become senseless and driven.

Furthermore, parallel changes have been detected in the brain chemicals and hormones of eating disordered females and long-distance runners that may explain how the anorexic tolerates starvation and the runner tolerates pain and exhaustion. In general, activity disordered men and women seem to be different biochemically than nondisordered individuals and are more easily led and trapped into a cycle of activity that is resistant to intervention.

Treatment for an Activity Disorder

The principles of treatment for individuals with activity disorders are similar to those with eating disorders. Medical issues must be handled, and residential or inpatient treatment may be necessary to curtail the exercise and to deal with depression or suicidality, but most cases should be able to be treated on an outpatient basis unless the activity disorder and an eating disorder coexist. This combination can present a serious situation rather quickly. When lack of nutrition is combined with hours of exercise, the body gets broken down at a rapid pace, and residential or inpatient treatment is often required.

Sometimes hospitalization is encouraged to patients as a way to relieve the vicious cycle of nutrient deprivation combined with exercise before a breakdown occurs. Activity disordered individuals often recognize that they need help to stop and know that they cannot do it with outpatient treatment alone. Eating disorder treatment programs are probably the best choice for hospitalizing those with activity disorder. An eating disorder facility that has a special program for athletes or compulsive exercisers would be ideal. (See the description of The Monte Nido Residential Treatment Facility on pages 251–274).

Therapy for an Activity Disorder

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It is important to keep in mind that activity disordered people tend to be highly intelligent, internally driven, independent individuals. They will most likely resist any kind of vulnerability such as going for treatment unless they become injured or face some kind of ultimatum. Excessive activity protects these individuals against desiring to get close, to take in something from another, or to depend on anyone.

Therapists will have to maintain a calm, caring stance with the goal of helping the individual define what he or she needs, rather than focusing on taking things away. Another therapeutic task is to help the individual receive and internalize the soothing functions the therapist can provide, thus promoting relationships over activity.

THERAPEUTIC ISSUES TO DISCUSS IN THE TREATMENT OF ACTIVITY DISORDER

• Overactivity of mind or body

• Body image

• Overcontrol of the body

• Disconnection from the body

• Body care and self-care

• Black-and-white thinking

• Unrealistic expectations

• Tension tolerance

• Communicating feelings

• Ruminations

• The meaning of rest

• Intimacy and separateness

The following section discusses a problem that is the polar opposite of too much activity—exercise resistance. "Exercise resistance" is a fairly new term used to describe an intense reluctance to exercise, particularly seen in women.

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